Please read the following agreement. It explains how to make and keep appointments, my cancellation policy, and my fee and payment policy as well as my policy on confidentiality and privacy.

Payment is always due at the time of service.

My fee is $90 for a 50-60 minute session.

I accept the following forms of payment:

Cash

Check

Visa

Master Card

Discover

There will be a $30.00 charge for checks returned for insufficient funds.

Insurance

I do not accept insurance; however some insurance companies cover my services. You will need to check with your own insurance company to see what they will cover if anything. I leave filing for insurance reimbursement up to each client since I don’t have a staff available to do billing and collection and adding staff would create a need for me to raise session costs, which I try to keep down. A statement is always available for you to see or print out at www.Schedule.care and will have the insurance code numbers that you will need to file for your insurance. Please ask if you need additional statements or a different type of receipt.

Appointments

Appointments can be made at any time from my web site www.cccoi.org at the appointment site www.Schedule.care if you need help scheduling you can email me at Dr.Boen@hushmail.com or call me at 260-413-5120 and leave a message and I will get back to you as soon as I can to help with the scheduling. My appointments are 60 minutes long. I prefer to work for longer periods at one time since it is often hard for people to schedule additional times due to busy schedules. This also allows us to get more work done in one session. .

Appointment Cancellations

It is your responsibility to remember and make appropriate arrangements to keep your appointment. If for any reason you cannot keep your appointment please call me as soon as possible or contact me by e-mail through your TherapyAppointment login at www.Schedule.care.

Cancellations received after your appointment and no shows will be charged at the full fee assigned to your appointment, except for personal emergencies or dangerous travel conditions due to the weather.

CONSENT FOR MENTAL HEALTH SERVICES

The State of Indiana requires all individuals sign a consent form before beginning services. Please complete the following information. Your returning this document electronically implies agreement and understanding of the Payment Agreement and Cancellation Policy aforementioned and your consent to the services provided. You and your spouse (if applicable) need to complete separate forms.

CONFIDENTIAL INFORMATION

First Name

*

MI

*

Last Name

*

Address

*

City

*

State

*

Zip Code

*

Email

*

Date of Birth

*

Do not enter anything in this field:

* indicates a required field

Please fill this field.

INFORMED CONSENT

I, the undersigned, agree and consent to participate in the mental health services offered and provided by Dan L. Boen, Ph.D., a licensed psychologist as defined by Indiana law. I understand that I am consenting and agreeing only to those mental health services that Dr. Boen is qualified to provide within the scope of his license, training, and supervision. I understand that a receipt is available to me any time for the service for each session at the same site I use to schedule my appointments, which is www.Schedule,care that contains all the information insurance companies normally need for reimbursement. It is my responsibility to pay my fee at time of service, submit my own claims to any third party payers such as insurance companies, and have any reimbursement due be sent directly to me should any reimbursement be owed. Dr. Boen is not in any way responsible for any reimbursement I may seek from third party payers.

I understand the policy for canceling scheduled appointments prior to my appointment or I will be charged my usual fee except for emergencies or dangerous travel conditions due to weather. All information shared with Dr. Boen is confidential except as allowed or called for under the laws of the State of Indiana or in the case where a couple or family is being counseled individually and information needs to be exchanged for therapeutic purposes or in the case where a church is paying or co-paying and information needs to be exchanged for billing or treatment purposes, except where the client notifies otherwise in writing.

I acknowledge I have read and understand the above information and a copy of the HIPPA notice is available to me on the CCCOI.org website.

By submitting this document, you are signing the document electronically.

You agree your electronic signature is the legal equivalent of your manual or handwritten signature on the document. By returning the completed document using any device, means or action, you consent to the legally binding terms and conditions of the document. You further agree that your signature on the document is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature. You are also confirming that you are the patient or guardian of the patient (if the patient is under age 18) authorized to enter into the agreement as described by the document.